Long-stay Wards Research Articles

The prevalence of pressure ulcers in hospitalised patients in a university hospital in India

To estimate the prevalence of pressure ulcers in hospitalised patients and any underlying or predisposing factors to ulceration. This cross-sectional study took place in a university hospital in Varanasi, India. A total of 445 patients hospitalised in medical and surgical wards were examined in a single day for the number, site and grade of pressure ulcers. Haemoglobin, serum albumin and blood sugar levels of patients with pressure ulcers were recorded. The prevalence of pressure ulcers was high (4.94%). Anaemia, malnutrition and diabetes were important risk factors, while morbidity due to pressure ulcers in long-stay wards, such as neurology, was exceptionally high (40.9%). Pressure ulcers remain one of the most neglected aspects of health-care provision in India and identifying their associated risk factors at an early stage may go a long way in preventing their occurrence.

Nurses’ Attitudes Toward People with Mental Illnesses in a Psychiatric Hospital in Singapore

<p>A positive attitude toward people with mental illnesses is a necessary dimension of psychiatric nursing practice. Although studies have been conducted in Israel and Australia to examine the attitudes of nurses toward people with mental illnesses, no such study had been conducted in Singapore. This study explored the factors influencing nurses’ attitudes toward and their involvement in caring for people with mental illnesses, and sought to establish the relevance and effects of mental health training on enhancing the nurses’ positive attitudes.</p><p>The study used a descriptive, self-administered questionnaire, which contained 24 statements scored on a Likert scale. Factors related to attitudes toward people with mental illnesses included age, professional qualification, years of psychiatric nursing experience, type of ward, and designation (i.e., position within the institution). The questionnaires were given to all of the local nurses working in a psychiatric hospital in Singapore, and 96% returned the questionnaires.</p><p>Results showed that nurses with any of the following characteristics had a more positive attitude: age group of 31 to 50; professional qualification of advanced diploma in mental health nursing, nursing degree, or post-basic certificate; or more than 10 years of psychiatric nursing experience. In addition, nursing officers had a more positive attitude than staff nurses or assistant nurses, and nurses working in the short-stay wards had more positive attitudes than those working in the long-stay wards.</p><div class="ftAuthorNotes"><p>Ms. Tay is Nurse Clinician, Ms. Pariyasami is Nurse Educator, Ms. Ravindran is Nursing Officer, and Ms. Ali and Ms. Rowsudeen were members of the Nursing Department, Institute of Mental Health, Woodbridge Hospital, Singapore.</p><p>The authors wish to acknowledge the following professionals for their support and guidance: Ms. Mary Yeo Kim Luang, Ms. Yeo Soo Gim, Associate Professor Chong Siow Ann, Ms. Mythily Subramaniam, Mr. Michael Wee, Ms. Tan Lay Wu, and Ms. Thavamani Ammavasi. They also thank all of the nursing staff of Woodbridge Hospital for completing the survey forms.</p><p>Address correspondence to Sim-Eng Clara Tay, RN, RMN, BHSc, Grad. Dip. Psychotherapy, Nurse Clinician, Nursing Department (Ward 33A), Institute of Mental Health, Woodbridge Hospital, 10 Buangkok View, Singapore 539747; e-mail: sim_eng_tay@imh.com.sg.</p></div>

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A positive attitude toward people with mental illnesses is a necessary dimension of psychiatric nursing practice. Although studies have been conducted in Israel and Australia to examine the attitudes of nurses toward people with mental illnesses, no such study had been conducted in Singapore. This study explored the factors influencing nurses' attitudes toward and their involvement in caring for people with mental illnesses, and sought to establish the relevance and effects of mental health training on enhancing the nurses' positive attitudes. The study used a descriptive, self-administered questionnaire, which contained 24 statements scored on a Likert scale. Factors related to attitudes toward people with mental illnesses included age, professional qualification, years of psychiatric nursing experience, type of ward, and designation (i.e., position within the institution). The questionnaires were given to all of the local nurses working in a psychiatric hospital in Singapore, and 96% returned the questionnaires. Results showed that nurses with any of the following characteristics had a more positive attitude: age group of 31 to 50; professional qualification of advanced diploma in mental health nursing, nursing degree, or post-basic certificate; or more than 10 years of psychiatric nursing experience. In addition, nursing officers had a more positive attitude than staff nurses or assistant nurses, and nurses working in the short-stay wards had more positive attitudes than those working in the long-stay wards.

Minimizing adverse effects on patients of involuntary relocation from long-stay wards to community residences.

This study examined the incidence of, and variables associated with, relocation trauma among 85 patients who moved from long-stay psychiatric wards to community care units as part of a hospital closure in Melbourne, Australia. Some participants moved directly from wards and some moved first to transitional units on the hospital grounds. Preparation for the transition, such as visits to the community care unit before the move, was documented, and severity of symptoms, aggressive behaviors, and preferences for living environments one month before and one month after the move were compared. Relocation trauma was measured one month after the move. After significant factors associated with trauma were determined, additional tests further discriminated these factors. Although 66 percent of participants were happy with community care units one month after the move, 18 percent preferred hospital living. Of 81 participants who had data on relocation trauma, 20, or 25 percent, met relocation trauma criteria. Preparation in a transitional unit reduced the likelihood of trauma, as did making six or more premove visits to the new facility and having a preparation period of more than 16 weeks. When preparation in a transitional unit, number of premove visits, and duration of preparation were considered together, only the number of premove visits and duration of preparation remained significantly associated with relocation trauma. Adverse effects of relocation on long-stay psychiatric patients may be minimized by the preparation of patients over a period of four months or more, with inclusion of six or more visits to the new facility. Moving via a transitional environment is not essential.

Enforcing patient rights or improving care? The interference of two modes of doing good in mental health care.

New state laws are intended to bring about formal changes. These juridical activities inevitably interfere with the content of care of substantially changing health care practice. The case is argued by means of an analysis of ethnographic material gathered in the long-stay wards of two psychiatric hospitals in the Netherlands. The question raised by the ethnography is which 'mode of doing good', juridical or caring, is relevant to daily practice. A 'mode of doing good' is defined as a pattern of ideals, procedures, routines and knowledge that is oriented towards a specific form of 'good care'. The interference of these different modes of doing good explains the impact of recent juridical changes in Dutch mental health care. The potential tensions between juridical and caring traditions are accommodated in different ways. Either juridical and caring modes resonate and gradually merge into new patterns of day-to-day practice, or there is dissonance and they remain oppositional. Rather than securing patient rights, juridical measures change daily life and work on the wards in far more complex ways.

Can multidisciplinary guidelines improve the palliation of symptoms in the terminal phase of dementia?

Dementia is a progressive terminal disease. More than 95% of patients will require 24-hour care either in long-stay hospital wards or in nursing homes at the end of life. There are many issues in the care of patients with dementia that parallel palliative cancer care, but relatively few patients with dementia currently access palliative care. Following an initial audit that found that many patients dying with dementia had symptoms that were not palliated, multidisciplinary guidelines were developed jointly by medical and nursing staff working in psychiatry for older people, together with pharmacy and palliative care staff. Following the implementation of guidelines, there was a significant decrease in the prescribing of antibiotics in the last 2 weeks of life and patients were much more likely to be prescribed analgesia, including opiates. This small study suggests that when developed collaboratively, multidisciplinary guidelines can have a positive impact on palliative care for non-oncology patients.

Schizophrenic patients, who still live in psychiatric hospitals despite decades of deinstitutionalization. Part 1 of the Hessian Deinstitutionalisation Study

Deinstitutionalization (DI) of most of the chronic long-stay patients has taken place in the last decades in Germany. However, a "residual" group of patients often remains in psychiatric hospitals, with an ongoing controversy on an appropriate type of their care (community based vs. hospital). Clinical, functional and social characteristics of such schizophrenic patients still residing in the long-stay wards in the German state of Hesse after decades of DI are presented. The n = 266 patients investigated displayed a marked degree of negative symptoms and moderate positive symptoms but, however, severe social disabilities. In addition, the patients were very dependent in daily living, had an extremely impoverished social network and leisure activities. The findings contribute to the research on "difficult-to-place" patients described in the literature.

Comparing and contrasting the role of family carers and nurses in the domestic health care of frail older people

Care in the community has been constructed on the basis of professional support for carers who, as a result of community care policy that has released highly dependant people from residential care and long-stay wards, are carrying out a wide range of tasks, including complex health care activities. The present paper examines the health care activities currently undertaken by family carers and the way in which they work with, and are supported by, professional nurses in the home. It compares and contrasts the approaches of both groups to care-giving for this client group. The authors conclude by making some suggestions for improving the way in which family carers and nurses work together in the home.

Misguided attitudes bar progress

There was a former prison officer on a long-stay ward for older people where I once worked who was so implacably opposed to change and so firmly entrenched in odd little routines that if some minute alteration to the day-to-day running of the place was proposed by staff, it was easier to avoid telling him and facing his inevitable opposition than to go ahead and act. We would consult the others, not with any confidence that they understood, but more from a sense of duty. Then we would do the deed - weekend trips to the coast, for example, or something radical like re-arranging the day room - and then brave the huffing that would persist until the prison man acclimatised to the new arrangements.

Improving the nutritional status of people with dementia.

The attention given to the nutritional needs of older adults receiving hospital care has been the subject of research over recent years. It has been suggested that older people are suffering from malnutrition as a result of poor nursing care. Those involved in care of persons with dementia are faced with considerable difficulty when trying to respond to their nutritional care needs and there is concern that there may come a time when the care team will withdraw food and fluid. However, in Southern Derbyshire we believe that we now have a set of standards for nutritional care of older adults with dementia that can ensure adequate and good nutrition despite the numerous and complex problems posed by dementia. This article discusses the progress of a sample of 20 residents of a long-stay ward over a period of 6 years and shows how a multidisciplinary team accessed, developed and applied an evidence base to practice to the benefit of the sample group. The outcomes show that malnutrition can be reversed, and that people who are considered to be in the final stages of dementia can improve their nutritional status.

From long-stay psychiatric hospital to Community Care Unit: evaluation at 1 year.

In the context of deinstitutionalization of psychiatric services, Community Care Units (CCUs) were developed to provide accommodation, clinical care and rehabilitation for patients discharged from the long-stay open wards of a large psychiatric hospital that was in the process of closing. CCUs are 20-bed units built in suburban locations and staffed on a 24-h basis by multidisciplinary clinical teams. An initial group of 125 hospital patients was assessed at 1 month pre-move, 1 month post-move, and again at 1 year, on range of measures covering clinical status, personal functioning, quality of life, residential preferences, aggressive behaviour, and social networks. Staff attitudes, relative and carer perceptions and preferences, and residential environments were also assessed. Most of the transferred patients were still resident in their CCU at 1 year. The clearest result was that patients showed improved quality of life in relation to their living environment. Comparison of the hospital and CCU environments showed that the latter were significantly less restrictive and regimented. Most relatives and carers also preferred the CCU. On average, symptom and disability levels were little changed at 1 year. Our results suggest that the CCU is an appropriate form of service delivery for most long-stay hospital inpatients, but that both more and less supervised settings are also required. While symptoms and disability were little changed at 1 year, it is possible that further follow-up may detect delayed or slow changes. Given the widespread replacement of psychiatric hospitals with community-based services, the future role of the CCU needs to be reviewed.

Care work and quality of care for older people: a review of the research literature

There is considerable research on work satisfaction and stress of care staff on the one hand and on quality of care and well-being of older people on the other. However, very little research in continuing-care settings for older people (nursing homes, residential homes and long-stay wards) links perceptions of workers (work satisfaction and stress) with the process of care (quality of care) and outcomes for residents/patients (well-being). This is a notable omission, given the emphasis of government policy on improving quality of health and social care services for vulnerable elderly people in the UK. The White Papers, The New NHS and Modernising Social Services and the National Priority Guidance for Health and Social Services for 2000–2003, all emphasize the importance of services that are responsive to local needs and which maintain and promote independence. The Centre for Policy on Ageing has been commissioned by the Department of Health to develop national standards for nursing and residential home care services for older people. This work will build upon recommendations of the Burgner Report and Achieving a Better Home Life, which identified areas for benchmarking. The national standards proposed under the forthcoming National Service Framework for Older People will underpin new legislation to regulate care services.

Discrepancy between subjective and objective ratings for negative symptoms

A better knowledge of the schizophrenic patients' awareness of negative symptoms may lead to a more empathic approach of these patients, especially within the context of rehabilitation programs. In order to examine the awareness of these symptoms, we have developed a self-rating scale, the Subjective Experience of Negative Symptoms scale (SENS; Selten et al., 1993). Since the items of this scale were taken from the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1989), the patient's rating can be compared to the psychiatrist's rating for the corresponding SANS item. Evidence for validity of the SENS was provided by a study that compared schizophrenic patients to patients with a depressive disorder and to normal subjects. Since the schizophrenic patients were found to report more impairments than the normal subjects did, it was inferred that they are at least `somewhat' aware of their negative symptoms. On the other hand, as they reported fewer impairments than did the patients with a depressive disorder, the results implied that the schizophrenic patients are less aware of their impairments than are patients with a depressive disorder (Selten et al., 1998). The aim of this letter is to describe the proportions of schizophrenic patients who participated in the above study and failed to report negative symptoms that were assessed as present by a psychiatrist. The patients (DSM-III-R criteria; 60 men and 26 women) were recruited from the mediumand long-stay wards of two mental hospitals. Patients who had a physical handicap that explained their impaired functioning were excluded. Other reasons for exclusion were the presence of mental subnormality (de®ned as the failure to complete primary education or having repeated more than one class at primary school), an organic mental disorder (DSM-III-R), recent or current substance abuse (DSM-III-R) and a current manic or major depressive episode (DSM-IIIR). Their mean age was 44.4 years (range 20±65). The length of admission varied greatly: less than a year in 26 patients and more than 5 years in 35 patients (median: 44.5 months). In one session the patient assessed himself with help of an interviewer. The interviewer gave a standardized explanation of the item in everyday language and asked a prescribed question, for instance: ``How much energy do you have?'' Next, he handed the patient a card that listed ®ve alternative answers: ``very little'' (1), ``little'' (2), ``average'' (3), ``a lot'' (4) and ``very much'' (5). Thus, the patient could indicate the presence of the symptom with a rating of ``1'' or ``2''. The patient was instructed to compare himself to other people of his age outside the hospital and had to choose one answer. In another session a psychiatrist (J.P.S.) assessed the patient using the SANS. His interrater reliability was sucient (ICC for SANS summary score: 0.81). The interval between both sessions was limited to a maximum of one week. In order to provide the psychiatrist with detailed information about the patient's daily activities, nurses completed the REHAB, a scale for the assessment of psychiatric disability which shows large overlap with negative symptom rating scales (Baker and Hall, 1988). The psychiatrist and the patient were blind to each other's ratings. After 2 months the measurements were repeated in 80 patients. SANS ratings of at least `2' (``mild, but de®nite'') were taken as scores indicating the presence of the symptom. Journal of Psychiatric Research 34 (2000) 11±13

Immobility as a major cause of bone remodeling in residents of a long-stay geriatric ward.

Residents of a long-stay geriatric ward at the University Hospital Basel were included in a study to investigate the effects of hypovitaminosis D and immobility. All 91 women (mean age 82.5 years) and 92 men (mean age 78.7 years) were enrolled in the study. Measurements included bone resorption, as measured by urinary deoxypyridinoline (dpd), serum 25-hydroxyvitamin D (25OHD), serum intact parathyroid hormone (iPTH), and their correlations with a four grade mobility score. Mobility score reflected the degree of weight bearing, ranging from walking independently to primarily bed bound. In 86% of all residents, serum 25OHD levels were below the normal limit of 12 ng/ml. Secondary hyperparathyroidism (HPT) was detected in 24% of all patients, using 55 pg/ml as the upper limit for serum iPTH. No significant correlation was found between urinary dpd and serum 25OHD or serum iPTH. Mobility index and both urinary dpd (f: P = 0.001, r = 0.37; m: P < 0.0001, r = 0.47) and serum calcium (female: P = 0.007, r = 0.28; male: P = 0.02, r = 0.24) were positively related. In institutionalized elderly people with a high prevalence of vitamin D deficiency serum intact PTH levels did not correlate with bone resorption as measured by urinary deoxypyridinolin. However, more immobile subjects had significantly higher excretion rates for urinary dpd and higher serum calcium levels. Our results suggest that in elderly people immobility may contribute to bone loss that might preempt the development of secondary HPT through elevation of serum calcium.

An overview of behaviour difficulties found in long‐term elderly care settings

Study objective To provide an understanding of the nature and prevalence of behaviour difficulties in long-term care facilities, to compare care settings and comment on the appropriateness of the need for specialist care. Design Nurses or carers implemented two rating scales in randomly selected settings. Setting Nursing homes, residential homes and NHS elderly long-stay wards. Subjects Elderly long-stay patients. Main results NHS and nursing home long-term care facilities show similar behaviour difficulties, with nursing homes experiencing more behaviour manifestations in most cases. Residential facilities have behaviour difficulties to a lesser extent. Conclusions Nursing homes have limited formal psychiatric intervention compared to NHS settings. Behaviour difficulties result in increased work for general practitioners and increased hospital referrals. More prospective research is required into the antecedents, effects and treatments of patients with behaviour difficulties in nursing homes. For example, it may be appropriate that specialist input is provided for nursing homes in order to implement behaviour intentions and contribute to the reduction of GP callouts and pharmacological interventions. Copyright © 1999 John Wiley & Sons, Ltd.

An overview of behaviour difficulties found in long-term elderly care settings

To provide an understanding of the nature and prevalence of behaviour difficulties in long-term care facilities, to compare care settings and comment on the appropriateness of the need for specialist care. Nurses or carers implemented two rating scales in randomly selected settings. Nursing homes, residential homes and NHS elderly long-stay wards. Elderly long-stay patients. NHS and nursing home long-term care facilities show similar behaviour difficulties, with nursing homes experiencing more behaviour manifestations in most cases. Residential facilities have behaviour difficulties to a lesser extent. Nursing homes have limited formal psychiatric intervention compared to NHS settings. Behaviour difficulties result in increased work for general practitioners and increased hospital referrals. More prospective research is required into the antecedents, effects and treatments of patients with behaviour difficulties in nursing homes. For example, it may be appropriate that specialist input is provided for nursing homes in order to implement behaviour intentions and contribute to the reduction of GP callouts and pharmacological interventions.

Calcidiol, calcitriol and parathyroid hormone serum concentrations in institutionalized and ambulatory elderly in Switzerland.

The aim of the present study was to measure concentrations of vitamin D metabolites and intact parathyroid hormone (iPTH) serum concentrations and an urinary bone resorption marker in two groups of elderly subjects, who differed markedly in their sedentary status and seasonality. 193 institutionalized elderly people of a long-stay geriatric ward (106 women: mean age 82; 87 men: mean age 78) were studied during wintertime. 312 ambulatory elderly people (109 women: mean age 74; 203 men: mean age 76) were studied during summertime. Concentrations of calcidiol (25(OH)D), calcitriol (1,25(OH)2D) and serum iPTH, as well as urinary N-telopeptides (NTX) were measured. Vitamin D deficiency (defined as serum 25(OH)D < 12 ng/ml) was present in 86% of institutionalized at the expected nadir (wintertime), compared to 15% of the ambulatory elderly subjects at the expected maximum (summertime). Serum calcitriol concentrations were significantly lower in institutionalized subjects (p = .0001). However intact PTH concentrations did not differ significantly between institutionalized and ambulatory elderly. Institutionalized and female subjects showed higher urinary NTX excretion (female institutionalized: 131.9; female ambulatory: 66.8/male institutionalized: 76.3 male ambulatory: 45.8 nmol/mmol). This cross-sectional study documented very low serum calcidiol and calcitriol concentrations and high urinary N-telopeptide excretion in institutionalized elderly people. There was no difference in serum iPTH concentrations between institutionalized and ambulatory elderly. This finding could not be explained by the differences in calcidiol and calcitriol concentration, nor urinary NTX excretion. These results suggest that other factors than vitamin D deficiency, such as lower mobility status and sedentary life style, might have an important role in the regulation of iPTH and mechanisms of bone loss in the elderly.

The role of environmental contamination with small round structured viruses in a hospital outbreak investigated by reverse-transcriptase polymerase chain reaction assay

In May 1994 an outbreak of vomiting and diarrhoea occurred in a 28-bed long-stay ward for the mentally infirm. The predominant symptoms were vomiting, diarrhoea, malaise and abdominal pain lasting for approximately 12 h in most cases. The attack rate was 62% ( 13 21 ) for patients and 46% ( 16 35 ) for staff members. Infection control measures were implemented (containment of infectious individuals, hand hygiene among staff and environmental decontamination) and the ward was closed to admissions. Affected staff were excluded from contact with patients and their food until asymptomatic for 72 h. The outbreak lasted for 17 days. Faecal samples from nine symptomatic persons were negative for bacterial enteric pathogens, Giardia, Cryptosporidium and group A rotavirus. Electron microscopy of 12 faecal samples and one sample of vomitus revealed small round structured virus (SRSV) particles in one faecal sample. A further 30 faecal samples and seven vomitus samples were tested by reverse transcription polymerase chain reaction (RT-PCR) for SRSV of which 12 (40%) and 1 (14%) were positive respectively. Twenty-eight throat swabs from symptomatic and asymptomatic patients were collected, three (9·5%) of which were positive for SRSV by RT-PCR. Thirty-six environmental swabs were collected on the affected ward, and 11 (30%) were positive by RT-PCR. Positive swabs were from lockers, curtains and commodes and confined to the immediate environment of symptomatic patients. The distribution of contamination supports the rationale of cohorting sick patients.

Home from home: residents' opinions of nursing homes and long-stay wards

To compare the levels of satisfaction expressed by residents of nursing homes with those of patients in geriatric long-stay wards. A structured satisfaction questionnaire containing 37 closed and two open questions was used to elicit responses from residents of nursing homes in the former South West Thames Regional Health Authority area. This was compared with a similar survey using the same questionnaire among patients in geriatric long-stay wards surveyed in 1989. respondents came from a sample of nursing homes chosen to be representative of both size and geographical location. Nursing homes were stratified by number of beds (1-19, 20-29, 30+) and clustered by location (to reflect the urban, semi-rural and coastal nature of the region). A random sample was drawn from each grouping (size and location) to yield a resident sample of 850 in 36 nursing homes. This figure was similar to the number of patients (808) in geriatric long-staywards surveyed in 1989. All eligible nursing home patients were assessed for physical dependency. Mental confusion was ascertained by the Abbreviated Mental Test Score (AMTS). Patients who scored three or less on the AMTS (indicative of severe confusion) or had dysphasia, profound deafness or concurrent serious illness were excluded from further study. 377 nursing home residents were able to complete the questionnaire and their answers were compared with those of 291 long-stay geriatric patients. The responses to the five themes--relations with staff, autonomy, amenities, privacy and social environment-show some minor differences between the two groups but what is more noticeable is the similarity of their views. This is important as much social policy assumes that the more 'homely' atmosphere of the nursing home should elicit higher levels of satisfaction than the 'institutional' setting of the hospital ward. We conclude that the difference between nursing homes and hospital wards in terms of their institutionalizing capacities is not as profound as policy-makers believe.

Ward atmosphere on a medium secure long-stay ward

This study focuses on the patients and staff within a newly developed long-stay/rehabilitation ward of a medium secure unit (MSU) for mentally disordered offenders. The aims were: to gain the opinions of both groups with regard to their ward environment, to test for differences between the groups and to determine the degree of perceived therapeutic care. The ward was compared with a pre-discharge ward. Data were obtained through self-report using a sample of 13 patients and 16 staff. Limited differences were recorded on both wards and on global comparisons. No patient characteristics were found to be significant when they were compared with the ward atmosphere results.